The Laryngoscope
Lippincott Williams & Wilkins, Inc.
© 2005 The American Laryngological,
Rhinological and Otological Society, Inc.
How I Do It
A Targeted Problem and Its Solution
Endoscopic Nasopharyngectomy for Patients
with Recurrent Nasopharyngeal Carcinoma
at the Primary Site
Tomokazu Yoshizaki, MD; Naohiro Wakisaka, MD; Shigeyuki Murono, MD; Yoshinori Shimizu, MD;
Mitsuru Furukawa, MD
Key Words: Nasopharyngeal carcinoma, surgery,
nasopharyngectomy, endoscopic surgery, recurrent
nasopharyngeal carcinoma.
INTRODUCTION
Primary nasopharyngeal carcinoma (NPC) is com-
monly treated by chemoradiotherapy. However, treatment
for recurrent or residual tumor in the nasopharynx is still
controversial. There are two main modalities for second-
or third-line treatments. One is re-irradiation, mainly
with an external beam, and, occasionally, brachytherapy
with an applicator. Re-irradiation is an established form
of salvage treatment. However, high-dose irradiation
sometimes causes severe morbidity such as skull-base and
brain necrosis, and occasionally results in death.1,2 The
other modality is surgery. In the view of the drawbacks of
high-dose irradiation, various surgical treatments against
recurrent and residual NPC have been developed. Most
surgeons report better local control and survival data than
the reports of re-irradiation studies.1– 6 Thus, treating
recurrent NPC with surgery has become accepted as the
standard treatment. Four surgical approaches, the trans-
palatal, the transmaxillary, the maxillary swing, and the
transmandibular, are used, depending on the recurrent T
(rT) stage and tumor location.2– 6 Although these methods
are reportedly less invasive than high-dose re-irradiation
From the Division of Otolaryngology, Head and Neck Surgery, Grad-
uate School of Medicine, Kanazawa University, Kanazawa, Japan.
Editor’s Note: This Manuscript was accepted for publication March
15, 2005.
Send Correspondence to Dr. Tomokazu Yoshizaki, Division of
Otolaryngology, Head and Neck Surgery, Graduate School of Medicine,
Kanazawa University, 13-1 Takaramachi, Kanazawa 920-8641, Japan.
E-mail: tomoy@orl.m.kanazawa-u.ac.jp
DOI: 10.1097/01.MLG.0000165383.35100.17
Laryngoscope 115: August 2005
techniques, there are some side effects, such as oronasal
fistula and palatal incompetence.2– 6
Less invasiveness and a clear view of the operation
field enabled endoscopic surgery to become the standard
surgical procedure for sinusitis. Moreover, the endoscope
is sometimes applied to pituitary surgery. However, be-
cause of the complicated structure of the nasal cavity and
the narrow space in the nasal cavity, both the endoscope
and the instruments reach only a limited area. In this
paper, we describe a modification of the endoscopic surgi-
cal procedure that remarkably improves these problems.
SURGICAL TECHNIQUE
Removal of the posterior half of the nasal septum is accom-
plished as follows. After injection of topical lidocaine to the nasal
septal mucosa on the bony part of septum, both sides of the
mucosa are cut and elevated from the perpendicular plate of the
ethmoid bone and the vomer, which compose the bony nasal
septum. High-frequency diathermy or ultrasonic cutting or coag-
ulating surgical devices are suitable for making a bloodless mu-
cosa incision. The bony part of the septum is widely removed by
chisel or osteotome as in ordinal nasal septoplasty. Then, the
septal mucosa is widely resected but with care taken not to expose
either naked nasal cartilage or septal bone. Otherwise, the pa-
tient will be bothered by long-standing nasal clustering after
surgery. After resection of the posterior half of the nasal septum,
the versatility of endoscopes and the instruments is increased
considerably (Figs. 1 and 2).
The ultrasonic cutting and coagulating surgical devices are
useful for the resection of widely exposed tumor with an adequate
mucosal surgical margin. We usually start with the anterior
mucosal incision using a curved-blade Harmonic scalpel. With an
endoscope holder, the surgeon can use both hands for tumor
resection: one hand for retraction of the tumor and the other hand
for manipulation of the scalpel or the elevator. Then, the lateral
wall, including the cartilaginous portion of the eustachian tube,
the roof, and the posterior wall margin, are resected.
Usually, an additional hemostat technique is not necessary.
Yoshizaki et al.: Endoscopic Nasopharyngectomy
1517
Fig. 1. Schematic representation of the operation field before (A)
and after (B) removal of the posterior half of the nasal septum. Axial
view of the nose and nasopharynx. Endoscope (star); inferior turbi-
nate (triangle).

Covering the wound surface with the free skin graft is preferable
but not essential. Because of the lack of nasal septum, fixation of
packing is not always successful, and thus, graft necrosis some-
times results. Suturing bilateral septal mucosa reduces cluster-
ing on the septal edge. A few days after the surgery, the patient
will usually be discharged.
COMMENTS
For anatomic reasons, en bloc resection of NPC, usu-
ally requiring nasopharyngectomy, has been a technically
difficult and invasive operation. Transseptal endoscopic
nasopharyngectomy is advantageous because of its tech-
nical ease, and it is less invasive. Currently, head and
neck surgeons have become familiar with endoscopic nasal
and sinus surgery. We treated four cases of patients with
rT2 NPC and one case of sinonasal malignant melanoma.
Except in one rT2 NPC case with massive parapharyngeal
extension, the tumors were successfully resected. This
Fig. 2. Endoscopic view from the right nasal cavity. Before (A) and
after (B) removal of the posterior half of the nasal septum. The
structure located in the left side of the nasal cavity and nasopharynx
indicated by the broken line (A) becomes visible (B). 1 ⫽ inferior
turbinate; 2 ⫽ middle turbinate; 3 ⫽ nasal septum; arrow ⫽ orifice
of the auditory tube; * ⫽ tumor.
technique is, therefore, quite powerful against tumors lo-
cated in the nasal to the nasopharyngeal area, and more-
over, the skull-base is also operable with this method as
well. However, tumors extending to far beyond the reach-
able range of the instruments cannot be successfully re-
sected. The anatomic limit for safe resection would be the
clivus superoposteriorly, the pharyngobasilar fascia later-

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1518
ally, and the anterior border of the inferior turbinate
anteriorly. Also, this method appears contraindicative for
cases in which exposure of carotid artery is expected.
Rupture of the carotid artery during and after operation
may result in death. Thus, such cases are treated with the
maxillary swing approach not only for obtaining sufficient
surgical field to treat the carotid artery but also for pro-
tection of the exposed carotid artery from wound infection
by covering with the vascularized free flap. Postoperative
complications are bleeding, nasal congestion by gauze
packing, and wound infection. In addition, long-standing,
naked, raw surface may result in scar formation. This
phenomenon might be attributable to previous irradia-
tion. The prognosis of rT3 and rT4 cases is poor even when
operated on with conventional nasopharyngectomy meth-
ods, indicating that endoscopic nasopharyngectomy would
not be helpful for the patients with advanced rT stage. We
cannot present data of the survival of patients treated
with endoscopic transseptal nasopharyngectomy because
of the rather short follow-up period. However, an en bloc
nasopharynx specimen resected by this method is almost
identical to the specimen resected with a conventional
method in that the tumor is localized within the nasal
Laryngoscope 115: August 2005
cavity and the nasopharynx. Thus, endoscopic transseptal
nasopharyngectomy is useful for the treatment of selected
cases with recurrent NPC.
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